1. April 29, 2015April 29, 2015April 29, 2015 Federal Tort Claims Act and Health Center Medical Malpractice Liability Protection Southeast Atlantic Health Disparities Collaboratives 2008 Annual Transformation Teams summit/Reunion March 28, 2008 Nashville, TN Martin Bree Triton Group, LLC. Martin Bree Triton Group, LLC.

2. April 29, 2015 Triton Group First Source of FTCA Program Information o Triton Group o 227 Hamburg. o Pompton Lakes, NJ 07442 o HRSA Contract No. 232-00-0097 oMartin J. Bree Susan Lewis o 772-873-1865 727-822-4271 o 772-873-1695 (fax) susanlewis@tampabay.rr.com o 856-625-8638 (cell) o mjbtriton@mac.commjbtriton@mac.com oRoger Fuydal o866-FTCA-HELP - Toll Free Marty Hiller (Free Clinics) o(866-382-2435) 216-382-4150 o 973-831-8395 (Fax) mhiller862@hotmail.com o tritongp@optonline.nettritongp@optonline.net First Source of FTCA Program Information o Triton Group o 227 Hamburg. o Pompton Lakes, NJ 07442 o HRSA Contract No. 232-00-0097 oMartin J. Bree Susan Lewis o 772-873-1865 727-822-4271 o 772-873-1695 (fax) susanlewis@tampabay.rr.com o 856-625-8638 (cell) o mjbtriton@mac.commjbtriton@mac.com oRoger Fuydal o866-FTCA-HELP - Toll Free Marty Hiller (Free Clinics) o(866-382-2435) 216-382-4150 o 973-831-8395 (Fax) mhiller862@hotmail.com o tritongp@optonline.nettritongp@optonline.net Triton Group, LLC

3. April 29, 2015 How the Program Works A scheme that provides immunity from lawsuit. Appears similar to an occurrence malpractice policy. Program in existence for 13 years. Very successful in terms of savings for health centers and coverage of health centers and staff. A scheme that provides immunity from lawsuit. Appears similar to an occurrence malpractice policy. Program in existence for 13 years. Very successful in terms of savings for health centers and coverage of health centers and staff. Triton Group, LLC

4. April 29, 2015 How the Program Works (cont.) Under FSHCAA Health Centers are eligible to be deemed “federal employees”. Provides immunity from lawsuit alleging medical malpractice. Plaintiff’s only remedy is claim under Federal Tort Claims Act (FTCA). Under FSHCAA Health Centers are eligible to be deemed “federal employees”. Provides immunity from lawsuit alleging medical malpractice. Plaintiff’s only remedy is claim under Federal Tort Claims Act (FTCA). Triton Group, LLC

5. April 29, 2015 How the Program Works (cont.) Who, what, when where? –Who is covered - Relationship to Health Center. –What is covered – medical malpractice. –Where is it covered – scope of project. –When is it covered – scope of employment. Who, what, when where? –Who is covered - Relationship to Health Center. –What is covered – medical malpractice. –Where is it covered – scope of project. –When is it covered – scope of employment. Triton Group, LLC

6. April 29, 2015 How the Program Works (cont.) Who is Eligible to be Deemed: Community Health Centers [section 330 (e)]. Migrant Health Centers [section 330 (g)]. Health Care for the Homeless [section 330 (h)]. Public Housing Primary Care [section 330 (i)]. Who is Eligible to be Deemed: Community Health Centers [section 330 (e)]. Migrant Health Centers [section 330 (g)]. Health Care for the Homeless [section 330 (h)]. Public Housing Primary Care [section 330 (i)]. Triton Group, LLC

7. April 29, 2015 How the Program Works (cont.) Who is covered - people –Employees. –Officers. –Directors. –Governing board members. –Contractors (some, not all). Who is covered - people –Employees. –Officers. –Directors. –Governing board members. –Contractors (some, not all). Triton Group, LLC

8. April 29, 2015 How the Program Works (cont.) Who is covered - Employees –All employees, full time or part time. –Volunteers are not employees. –Employees get a W-2 at end of year. Who is covered - Employees –All employees, full time or part time. –Volunteers are not employees. –Employees get a W-2 at end of year. Triton Group, LLC

9. April 29, 2015 How the Program Works (cont.) Who is covered - Contractors –Any full time contract provider (over 32 1/2 hours per week). –Part time contract provider of services in the fields of family practice, ob-gyn, general internal medicine, or general pediatrics. –Contract must be between the deemed health center and the individual provider. –Contracts between the deemed health center and a corporation (including Professional Corporations) are not covered. Who is covered - Contractors –Any full time contract provider (over 32 1/2 hours per week). –Part time contract provider of services in the fields of family practice, ob-gyn, general internal medicine, or general pediatrics. –Contract must be between the deemed health center and the individual provider. –Contracts between the deemed health center and a corporation (including Professional Corporations) are not covered. Triton Group, LLC

10. April 29, 2015 How the Program Works (cont.) Contractors –42 U.S.C. §233(g)(1)(A) “…any contractor of such an entity who is a physician, or other licensed or certified health care practitioner”. –42 U.S.C. §233 (g)(5) “an individual may be considered a contractor”. –El Rio Case Contractors –42 U.S.C. §233(g)(1)(A) “…any contractor of such an entity who is a physician, or other licensed or certified health care practitioner”. –42 U.S.C. §233 (g)(5) “an individual may be considered a contractor”. –El Rio Case Triton Group, LLC

11. April 29, 2015 How the Program Works (cont.) What is covered? –Medical malpractice. –More specifically, medical, surgical, dental and related activities (if within the scope of employment and scope of project). What is covered? –Medical malpractice. –More specifically, medical, surgical, dental and related activities (if within the scope of employment and scope of project). Triton Group, LLC

12. April 29, 2015 How the Program Works (cont.) Where is it covered – within the scope of project –Only incidents that occur within the scope of the project are covered. (See Policy Information Notice 2008-01). –Scope of Project are the activities described in the grant application that are approved by Public Health Service via Notice of Grant Award. –An existing Scope of Project cannot be changed in a grant application. There is a separate process. –A grant award for a new section 330 activity does change the Scope of Project. Where is it covered – within the scope of project –Only incidents that occur within the scope of the project are covered. (See Policy Information Notice 2008-01). –Scope of Project are the activities described in the grant application that are approved by Public Health Service via Notice of Grant Award. –An existing Scope of Project cannot be changed in a grant application. There is a separate process. –A grant award for a new section 330 activity does change the Scope of Project. Triton Group, LLC

13. April 29, 2015 How the Program Works (cont.) When is it covered –Coverage is only for acts that are within the scope of employment of the covered individual. –No Moonlighting. –Must be acting on behalf of the deemed entity. When is it covered –Coverage is only for acts that are within the scope of employment of the covered individual. –No Moonlighting. –Must be acting on behalf of the deemed entity. Triton Group, LLC

14. April 29, 2015 FTCA Procedures Procedure –Plaintiff files administrative claim against the United States. –DHHS reviews claim and may deny it, pay it or offer a settlement. –If DHHS denies claim plaintiff may file suit. –If DHHS does not act on claim within six months plaintiff may file suit. –When suit is filed case transferred to DOJ. –DOJ may attempt to settle suit otherwise it goes into litigation. Procedure –Plaintiff files administrative claim against the United States. –DHHS reviews claim and may deny it, pay it or offer a settlement. –If DHHS denies claim plaintiff may file suit. –If DHHS does not act on claim within six months plaintiff may file suit. –When suit is filed case transferred to DOJ. –DOJ may attempt to settle suit otherwise it goes into litigation. Triton Group, LLC

15. April 29, 2015 FTCA Procedures Procedure –Plaintiffs often file suit in state court. –What to do: Immediately fax complaint and deeming letter to: Lisa Barsoomian Department of Health and Human Service Office of General Counsel (OGC) 202-619-2922 (Fax) 202-619-2155 (Voice) Have health center attorney request extension of time to reply. Procedure –Plaintiffs often file suit in state court. –What to do: Immediately fax complaint and deeming letter to: Lisa Barsoomian Department of Health and Human Service Office of General Counsel (OGC) 202-619-2922 (Fax) 202-619-2155 (Voice) Have health center attorney request extension of time to reply. Triton Group, LLC

16. April 29, 2015 Potential Problems Contracts. Sub-Recipients. Scope of Project - Sites and Services. Billing Arrangements. Americans with Disabilities Act, Rehabilitation Act, Civil Rights Act. Nursing Homes Contracts with Correctional Institutions Non-Health Center Patients Contracts. Sub-Recipients. Scope of Project - Sites and Services. Billing Arrangements. Americans with Disabilities Act, Rehabilitation Act, Civil Rights Act. Nursing Homes Contracts with Correctional Institutions Non-Health Center Patients Triton Group, LLC

17. April 29, 2015April 29, 2015April 29, 2015 Scope of Project New Policy - PIN 2008-01 Baseline Scope Verification Process - PAL 2008-01 New Policy - PIN 2008-01 Baseline Scope Verification Process - PAL 2008-01

18. April 29, 2015 Important issues –Insurance requirements of hospitals and Health Maintenance Organizations. –National Practitioner Data Bank. –Other Insurance. –Deeming Applications. –Credentialing – a critical issue. –Emergency Response - PIN 2007-16 –Insurance requirements of hospitals and Health Maintenance Organizations. –National Practitioner Data Bank. –Other Insurance. –Deeming Applications. –Credentialing – a critical issue. –Emergency Response - PIN 2007-16 Triton Group, LLC

19. April 29, 2015 Non-Health Center Patients Federal Register Notice September 25, 1995 (Volume 60 Number 185) page 49417 – 49418. –Hospital On-Call Requirements. –Cross Coverage Arrangements. –Community Activities. Other situations require a “Particularized Determination” See 99-08. Federal Register Notice September 25, 1995 (Volume 60 Number 185) page 49417 – 49418. –Hospital On-Call Requirements. –Cross Coverage Arrangements. –Community Activities. Other situations require a “Particularized Determination” See 99-08. Triton Group, LLC

20. April 29, 2015 National Practitioner Data Bank (NPDB) HRSA Participates in the NPDB. 42 U.S.C. §401 – 431. Assistant Secretary of Health elects to require PHS agencies to report – October 1987. http://www.npdb-hipdb.com. HRSA Participates in the NPDB. 42 U.S.C. §401 – 431. Assistant Secretary of Health elects to require PHS agencies to report – October 1987. http://www.npdb-hipdb.com. Triton Group, LLC

21. April 29, 2015 Other Insurance Needs Gap or Wrap-around: covers medical malpractice not covered by FTCA. –Volunteers –Outside Scope of project –Contracts with corporations –Contracts with part time specialists –Peer review (maybe) Tail Insurance General Liability Insurance Directors and Officers Liability Proof of malpractice coverage – Triton Group Gap or Wrap-around: covers medical malpractice not covered by FTCA. –Volunteers –Outside Scope of project –Contracts with corporations –Contracts with part time specialists –Peer review (maybe) Tail Insurance General Liability Insurance Directors and Officers Liability Proof of malpractice coverage – Triton Group Triton Group, LLC

22. April 29, 2015 Deeming Applications 2007 Policy –New organizations (never deemed before): Submit application found in PIN 99-08 to BPHC. –Previously deemed entities Submit application found in PAL 2007-02 to BPHC. Due July 1, 2007. –All participating health centers should have received 2008 deeming letters by now. 2008 Policy –Tentative due date June 1, 2008. (Look for a Program Assistance Letter around Mid April.) 2007 Policy –New organizations (never deemed before): Submit application found in PIN 99-08 to BPHC. –Previously deemed entities Submit application found in PAL 2007-02 to BPHC. Due July 1, 2007. –All participating health centers should have received 2008 deeming letters by now. 2008 Policy –Tentative due date June 1, 2008. (Look for a Program Assistance Letter around Mid April.) Triton Group, LLC

23. April 29, 2015 Program Value Malpractice Premium Savings Studies conducted for Triton Group by Princeton Insurance Company and Huggins Actuarial Services. Premiums calculated for 2002, 2005, 2006 Used Uniform Data System (UDS) data for deemed Health Centers Studies conducted for Triton Group by Princeton Insurance Company and Huggins Actuarial Services. Premiums calculated for 2002, 2005, 2006 Used Uniform Data System (UDS) data for deemed Health Centers Triton Group, LLC

24. April 29, 2015 Program Value Malpractice Premium Savings Study Methodology Used Occurrence Premiums with $1m/3m limits. Premiums include 25% for taxes, profits, commissions, etc. Each deemed Health Center rated by its specific territory. Rates based on Full Time Equivalents by specialty. Premium increased by 10% to cover corporation and allied personnel. Used Occurrence Premiums with $1m/3m limits. Premiums include 25% for taxes, profits, commissions, etc. Each deemed Health Center rated by its specific territory. Rates based on Full Time Equivalents by specialty. Premium increased by 10% to cover corporation and allied personnel. Triton Group, LLC

25. April 29, 2015 Program Value Malpractice Premium Savings Study Results 2002 Savings for deemed centers - $164,000,000 2005 Savings for deemed centers - $180,000,000 2006 Savings for deemed centers - $184,000,000 2007 Savings for deemed centers - $192,000,000 Extrapolating from the studies: total savings since 1993 $1.6 billion 2002 Savings for deemed centers - $164,000,000 2005 Savings for deemed centers - $180,000,000 2006 Savings for deemed centers - $184,000,000 2007 Savings for deemed centers - $192,000,000 Extrapolating from the studies: total savings since 1993 $1.6 billion Triton Group, LLC

26. April 29, 2015 HRSA FTCA CLAIMS PER FISCAL YEAR Triton Group, LLC

27. April 29, 2015 Triton Group, LLC

28. April 29, 2015 Incident Status Summary Health Center FTCA Malpractice Incidents Oct 1994 – Jun 30, 2006 1,456 Medical Incidents –412 Deemed Health Centers (DHCs) –51 States/Territories 60% w/ final disposition 283 Obstetrics Related Claims –151 DHCs –36 States/Territories 1,456 Medical Incidents –412 Deemed Health Centers (DHCs) –51 States/Territories 60% w/ final disposition 283 Obstetrics Related Claims –151 DHCs –36 States/Territories Triton Group, LLC

29. April 29, 2015 Severity of Injuries Resulting from Malpractice Incidents % of total NATIONAL N=1,456 Triton Group, LLC

30. April 29, 2015 Nature of Occurrence Triton Group, LLC Previously Reported 1Q072Q073Q074Q07Previous/Total Obstetrics Related1510125305/347 Diagnosis Related16141315418/474 Treatment Related7111610284/328 Medication Related5785126/151 Surgery Related231383/92 Other Miscellaneous0010125/126 Monitoring Related200016/18 Equipment/Product Related 00018/9 Anesthesia Related00007/7 IV & Blood Products Related 00004/4

31. April 29, 2015 Triton Group, LLC

32. April 29, 2015 Risk Management Health Centers are expected to use a portion of savings to provide risk management services. (PIN 99-08 Para. XVIII). NACHC –risk management training for groups of health centers. Inspector General report on risk management in health centers. Triton Group can provide risk management services. Health Centers are expected to use a portion of savings to provide risk management services. (PIN 99-08 Para. XVIII). NACHC –risk management training for groups of health centers. Inspector General report on risk management in health centers. Triton Group can provide risk management services. Triton Group, LLC

33. April 29, 2015 Credentialing and Privileging PIN 2002-22 Credentialing and privileging required of all licensed or certified health care practitioners. Process for Licensed Independent Practitioners (LIPs) generally mimics JCAHO. Non-LIPs requires primary source verification of only license or certification. Volunteers included. Triton Group, LLC

34. April 29, 2015 Risk Management Findings from Health Center Claims Credentialing and Privileging –Competence of providers Medical Records –Legibility –Completeness –Signatures –Availability Birth Injuries –Existence and Proper use of protocols Informed Consent Credentialing and Privileging –Competence of providers Medical Records –Legibility –Completeness –Signatures –Availability Birth Injuries –Existence and Proper use of protocols Informed Consent Triton Group, LLC

35. April 29, 2015 Recent Risk Management Recommendations ( from HRSA Contractor - Keystone Peer Review Organization ) Training/CME: –Monitoring Pitocin Administration –Cord prolapse –GBS testing Preceptor needs in labor and delivery setting Training/CME: –Monitoring Pitocin Administration –Cord prolapse –GBS testing Preceptor needs in labor and delivery setting Triton Group, LLC

36. April 29, 2015 Recent Risk Management Recommendations Illegible and/or Inadequate Medical Record Documentation –Accurate, complete and legible –Documentation of scheduled exams –Training in proper documentation –Use problem list and flow sheets for lab and meds –Encourage use of EMR –Documentation of conversations with patients or specialists Illegible and/or Inadequate Medical Record Documentation –Accurate, complete and legible –Documentation of scheduled exams –Training in proper documentation –Use problem list and flow sheets for lab and meds –Encourage use of EMR –Documentation of conversations with patients or specialists Triton Group, LLC

37. April 29, 2015 Recent Risk Management Recommendations Policies/Procedures/Protocols –Lack of policies/procedure/protocol in 32% of cases reviewed –Examples: chest pain, handling of abnormal test results, adherence to ACOG 30 Minute “Decision to Incision” guideline. –Every health center should have its own customized set of well defined policies and procedures –Lack of algorithm for DVT/Pulmonary embolism prophylaxis –Lack of vaccine schedule for high-risk patients Policies/Procedures/Protocols –Lack of policies/procedure/protocol in 32% of cases reviewed –Examples: chest pain, handling of abnormal test results, adherence to ACOG 30 Minute “Decision to Incision” guideline. –Every health center should have its own customized set of well defined policies and procedures –Lack of algorithm for DVT/Pulmonary embolism prophylaxis –Lack of vaccine schedule for high-risk patients Triton Group, LLC

38. April 29, 2015April 29, 2015April 29, 2015 Recent Risk Management Recommendations Training: Shoulder Dystocia Drills Other Lack of effective communication in 29% of cases: Failure to communicate plan of care with patients Failure to inform ptients of lab results Training: Shoulder Dystocia Drills Other Lack of effective communication in 29% of cases: Failure to communicate plan of care with patients Failure to inform ptients of lab results Triton Group, LLC

39. April 29, 2015 Triton Group First Source of FTCA Program Information o Triton Group o 227 Hamburg. o Pompton Lakes, NJ 07442 o HRSA Contract No. 232-00-0097 oMartin J. Bree Susan Lewis o 772-873-1865 727-822-4271 o 772-873-1695 (fax) susanlewis@tampabay.rr.com o 856-625-8638 (cell) o mjbtriton@mac.commjbtriton@mac.com oRoger Fuydal o866-FTCA-HELP - Toll Free Marty Hiller (Free Clinics) o(866-382-2435) 216-382-4150 o 973-831-8395 (Fax) mhiller862@hotmail.com o tritongp@optonline.nettritongp@optonline.net First Source of FTCA Program Information o Triton Group o 227 Hamburg. o Pompton Lakes, NJ 07442 o HRSA Contract No. 232-00-0097 oMartin J. Bree Susan Lewis o 772-873-1865 727-822-4271 o 772-873-1695 (fax) susanlewis@tampabay.rr.com o 856-625-8638 (cell) o mjbtriton@mac.commjbtriton@mac.com oRoger Fuydal o866-FTCA-HELP - Toll Free Marty Hiller (Free Clinics) o(866-382-2435) 216-382-4150 o 973-831-8395 (Fax) mhiller862@hotmail.com o tritongp@optonline.nettritongp@optonline.net Triton Group, LLC